The Haven Of Paris

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the Power of Attorney was notified, as the facility abuse prevention policy directs.On 8/22/25 at 12:40 pm V1 Administrator/Abuse Prevention Coordinator said the nurses should be documenting accurately if they aren't getting a hold of a family and the doctor. The nurses are to report to the families about any resident-to-resident altercations/abuse. The facility Abuse Policy dated as revised 01/09/24 documents the following: The Facility will report all allegations of abuse immediately to the Administrator and timely, to the proper authorities to include IDPH (Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA (Power of Attorney), and M.D. (Physician) in a timely manner.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Nurse (unidentified) and CNA (V5, Certified Nursing Assistant) came in and had her (Resident R4) let go. I have not been mistreated any other time.On 8/22/25 at 8:40 am V1, Administrator/Abuse Prevention Coordinator V1 stated that the 6/18/25 abuse allegations above was not Resident R5 and Resident R4. V1 said V1 fixed the report and gave it (the second report) to this surveyor the day before. V1 said the investigation was the altercation between Resident R4 and Resident R6 and V1 has not sent an updated report to IDPH. V1 said she 'should probably do that'. V1 said V12, Licensed Practical Nurse did the skin assessment and said there was no injury to Resident R6's skin. On 8/22/25 at 9:25 am V1, Abuse Prevention Coordinator/ Administrator provided the third resident to resident investigation report. V1 said all three of the abuse investigation reports dated 6/18/25 regarding Resident R4 and Resident R6 provided on survey, are the same occurrence. The last one included that Resident R4 did grabbed Resident R6's wrist and That should have been in the investigation report to begin with. Each of the IDPH abuse investigations reports dated 6/18/25 document the Ombudsman, and POA, were notified.Resident R6's Nursing Note dated 6/18/2025 at 2:46 pm documents the following: Note Text: Upon responding to alarm sounding in room across the hall from resident; a staff member observed this resident standing from W/C (wheelchair) and grasping another female resident by both wrists. Staff immediately separated the residents and notified the appropriate supervisor and abuse coordinator. Placed a phone call to (V28, Resident R4's Healthcare Power of Attorney/HPOA) and informed of the observation of resident having ahold of another female (Resident R6) by both wrists and that per protocol was also reported to PCP (Primary Care Provider) and all appropriate IDT (Interdisciplinary Team) members. HPOA expressed understanding and appreciation for the call and stated will not be coming to visit today due to the inclement weather but plans to come tomorrow. HPOA has no concerns or other questions. The facility abuse policy dated 1/9/24 document the following: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed repeatedly to operationalize their abuse prevention policy by failing to notify the Ombudsman of abuse allegations. This failure affected seven of nine residents (Resident R3 -Resident R7) reviewed for abuse on the sample list of 18. Findings include:1. R'4s/Resident R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents Resident R3 smacked Resident R4's face, and the Ombudsman was notified, as the facility abuse prevention policy directs.2. Resident R4/Resident R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents Resident R4 swatted Resident R5's back, and the Ombudsman was notified, as the facility abuse prevention policy directs. 3. Resident R4/Resident R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents Resident R4 grabbed Resident R6's wrist, and the Ombudsman was notified, as the facility abuse prevention policy directs. 4. Resident R7's IDPH report dated 8/19/25 documents Resident R7 was handling rough by an unidentified nursing staff named ( V11, Nursing staff) causing a bruise to Resident R7's arm, and the Ombudsman was notified, as the facility abuse prevention policy directs. All of the above reports were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the Ombudsman was notified of the alleged abuse.On 8/21/25 at 11:13 AM V20, Ombudsman discussed the the above alleged abuse investigation reports with the corresponding dates.

V20 said V20 reviewed all V20's correspondence with the facility over this time frame and associated dates.

V20, Ombudsman stated he was not notified by the facility of any of the above allegations. V20, said V20 reviewed his notes, emails and phone calls. V20 also stated he was in the facility last week and was present

during the facility Resident Council Group meeting. V20 stated the facility did not notify V20 in person, of any of the abuse/injury of unknown allegations documented above.The facility Abuse Policy dated as revised 01/09/24 documents, The Facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH ( Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA ( residents Power of Attorney), and M.D. (Physician) in a timely manner.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based interview and record review, the facility failed to report allegations of resident to resident physical abuse, staff to resident physical abuse, and injuries of unknown origin to the police department and physician, in accordance with the facility policy. This failure affected five of nine residents (Resident R3-Resident R7) reviewed for abuse on the sample list of 18.Findings include: 1. R'4s/Resident R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents Resident R3 smacked Resident R4's face, and the local police department and physician were notified. 2. Resident R4/Resident R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents Resident R4 swatted Resident R5's back, and the local police department and physician were notified. 3. Resident R4/Resident R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents Resident R4 grabbed Resident R6's wrist, and the local police department and physician were notified. 4. Resident R7's IDPH report dated 8/19/25 documents Resident R7 was handling rough by an unidentified nursing staff causing a bruise to Resident R7's arm, and the local police department and physician were notified. All of the above reports were documented by V1, Administrator/ Abuse Prevention Coordinator. Each of the above reports document that the local police department and the physician were notified, as the facility abuse prevention policy directs.On 8/21/25 at 10:20 AM, V19, Supervisor, Local Police Department stated the police department has no records, reports or dispatch calls of the facility contacting them regarding any of the above report.On 8/22/25 at 1:10 PM, V3, Medical Director/Physician (MD) reviewed V3, MD's records, facsimiles and phone calls on each of the above allegations of abuse. V3 said had not been notified of any of the above allegations. V3,MD also said that on-call physicians report all events in the facility to V3, MD. V3 said he does not see any evidence from

the on-call providers that reflects they were notified of the above abuse investigations.On 8/22/25 at 12:40 pm V1 Administrator/Abuse Prevention Coordinator stated I called the police, and they asked if I wanted them to come out and I said no. I have nothing to show that I called and I don't keep my phone calls on my cell phone. I have no proof. I will have to get proof from now on. I will get a name or report number from the Police. V1 also stated As far as family and the physician, the nurses should be documenting accurately if

they aren't getting a hold of a family and the doctor. That is what I go by in my investigation. I know I talked to (V23 Power of Attorney/Resident R6's Family) about other things. The nurses are to report to the families about any resident-to-resident altercation. I guess I can't prove that either.The facility Abuse Policy dated as revised 01/09/24 documents the following: investigation has been complete. The Facility will report all allegations of abuse immediately to the Administrator and timely to the proper authorities to include IDPH ( Illinois Department of Public Health), Ombudsman, Local P.D (Police Department), POA ( residents Power of Attorney), and M.D. (Physician) in a timely manner.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to complete a thorough investigation by failing to

interview families that are frequently in the facility, and other residents residing in the facility, that may have knowledge of alleged abuse. This failure had the potential to affect five of nine residents (Resident R3- Resident R7) reviewed for abuse on the sample list of 18. Findings include:R'4s/Resident R3's IDPH resident to resident physical abuse investigation report dated 7/5/25 documents Resident R3 smacked Resident R4's face. The facility investigation determined

this allegation to be unfounded, though no families or other residents were interviewed. 2. Resident R4/Resident R5 IDPH resident to resident physical abuse investigation report dated 6/21/25 documents Resident R4 swatted Resident R5's back.

The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 3. Resident R4/Resident R6 IDPH resident to resident physical abuse investigation report dated 6/18//25 documents Resident R4 grabbed Resident R6's wrist. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. 4. Resident R7's IDPH report dated 8/19/25 documents Resident R7 was handling rough by an unidentified nursing staff causing a bruise to Resident R7's arm. The facility investigation determined this allegation to be unfounded, though no families or other residents were interviewed. On 8/22/25 at 8:40 am V1, Administrator confirmed the abuse investigation ( Resident R3-Resident R7) provided throughout the survey (8/19/25 - 8/22/25) are complete. V1 then confirmed she did not interview families that visit the facility frequently, or other residents who may have knowledge of alleged abuse incidents. The facility's Abuse Policy dated as revised 01/09/24 documents the following, The facility immediately and thoroughly investigates all allegations of abuse to include but not limited to interviews of residents and staff, visitors, vendors.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm

updated as they were supposed to be and new interventions should have been documented after each of

the abuse allegations.The facility's Abuse Policy dated as revised 01/09/24 documents the following: Implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on observation, interview, and record review, the facility failed to provide a full-time director of nurses to oversee and coordinate nursing services provided within the facility. This failure has the potential to affect all 83 residents residing in the facility.Findings include:During the survey 8/19/25 through 8/22/25 there was no Director of Nursing (DON) in the building.On 8/19/25 at 10:10 am V1, Administrator/Abuse Prevention Coordinator stated V2, previous Director of Nursing's last day employed for the facility was Friday 8/15/25.

V1 stated she has not hired a Registered Nurse for the DON position, nor does the facility have an Acting DON to provide oversite of the nursing services.The facility resident roster dated 8/19/25 documents 83 residents reside in the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Paris

1011 North Main Street Paris, IL 61944

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review, the facility failed repeatedly to maintain complete and accurate medical records for one of nine residents ( Resident R6) reviewed for abuse/injury of unknown origin on the sample list of 18.Findings include:Resident R6's Physician Adult Health Exam, Routine Nursing Home Follow-Up. notes dated 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25 document Resident R6 was assessed by V3, Medical Director (Physician). These notes were signed by V3, Medical Director. V3, MD documented Resident R6 'Integumentary (skin)' assessments indicates Resident R6 had left cheek and left, lower rib cage bruises on each of these assessment. On 8/22/25 at 1:10 PM V3, Medical Director reviewed Resident R6's medical record documentation and said he now recognized his documentation was not accurate in V3, MD Nursing home visit notes that he documented on 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25. V3 confirmed Resident R6 had a fall in December 2024 and continued with bruises in January but did not have bruising on the above mentioned dates. V3, MD acknowledged this was a documentation error. V3, MD also said V3, MD will add an addendum to each of those progress notes.Resident R6's revised Progress notes dated 2/20/25, 4/10/25, 4/17/25, 6/19/25 and 7/10/25 have the following addendum signed by V3, MD: C: PHC NH (Point Click Care Nursing Home) Addendum: Integumentary: Bruising noted to left cheek and left lower ribs was added to chart due to documentation error. ZOO.DO: Encounter for general adult medical examination without abnormal findings.

Event ID:

Facility ID:

If continuation sheet